Specialties & Topics
- Arthritis/Rheumatic Disease
- Breast Cancer
- GERD/Peptic Ulcers
An ongoing dialogue on HIV/AIDS, infectious diseases,
March 1st, 2012
Post-Exposure Prophylaxis, the World’s Most Outdated HIV Guidelines, and What To Do About Them
Every time I cover HIV prevention in a lecture, it’s always kind of embarrassing to cite the “official” post-exposure prophylaxis (PEP) guidelines, which are here (non-occupational) and here (occupational).
That’s right, they were last updated in 2005, the year of Hurricane Katrina.
Yes — more than six years ago. The alternative choices seem particularly curious (read: don’t do it) today — indinavir/ritonavir or efavirenz for PEP? You’ve got to be kidding me.
Because here’s a short list of what’s happened since then related to the HIV prevention front:
- HPTN 052
- An HIV vaccine study that, marginal efficacy aside, at least gave us a sense of “community risk” in a low-moderate prevalence area
- Landmark studies in perinatal prevention, such as this one
- That great wave of HIV drug development, which included darunavir, maraviroc, raltegravir, and etravirine
No, there’s not been much new on occupational risk of HIV acquisition, which fortunately remains incredibly rare –and has always been a relatively data-free zone. (For the record, this is pretty much it here.)
So what’s an ID/HIV specialist to do?
I’ve been told that the next round of PEP guidelines is in development, but frankly the existing guidelines have been out of date for so long that something/anything has to be done.
Hence I welcome the imminent publication of this paper on the use of tenofovir/FTC and raltegravir for non-occupational post-exposure prophylaxis.
Yes, the study is small, and there’s no control group; furthermore, given the rarity of transmission, it can’t really estimate the preventive efficacy of this intervention — we’ll probably never have that.
But it provides at least some support behind what we’ve been doing now for several months, which is frequently replacing lopinavir/r with raltegravir — leading to much better tolerability of the PEP regimen.
And our hospital is about to make it official. From my colleague Sigal Yawetz, who heads up our PEP program, comes the following:
First line empiric therapy, not pregnant, no renal problems: tenofovir/FTC, raltegravir
First line therapy, pregnant (or breast feeding, continues to breast feed though not recommended): zidovudine/3TC, lopinavir/r
First line therapy, abnormal renal function: zidovudine/3TC, raltegravir
For any exposure to known infected person: ART to be selected by HIV expert
There — PEP Guidelines updated!
Paul E. Sax, MD
Learn more about HIV and ID Observations.
- Mystifying Abbreviations on Daily Medical Rounds (46)
- Should Doctors Still Be Allowed to Wear White Coats? You Decide (43)
- Are ID Doctors the Worst Dressed Specialists? (39)
- A Ridiculously Long Post: How EHRs Expose Unspoken Hierarchies Within Medicine — Or Maybe Are Just Bad (34)
- Which Infectious Diseases Do We Fear Too Much? Which Not Enough? (33)
- A Ridiculously Long Post: How EHRs Expose Unspoken Hierarchies Within Medicine — Or Maybe Are Just Bad
- The Sanford Guide — 46 Editions Later, Still Going Strong
- Lots of College Graduations ID Link-O-Rama
- Zika, Baseball, and Waiting for a “New Normal”
- Drug Prior Authorizations Are a Very Blunt Tool for Cost Containment — And They’re Annoying
Subscribe to HIV and ID Observations via Email
Physician's First WatchToday's breaking medical news
- Abacavir AIDS aids clinical care antibiotics antiretroviral therapy ART atazanavir baseball CDC C diff CROI cure darunavir dolutegravir efavirenz elvitegravir etravirine FDA HCV hepatitis C HIV HIV testing ID Learning Unit Infectious Diseases influenza lamivudine Link-o-Rama lyme disease Massachusetts MRSA Patient Care PEP Policy PrEP prevention primary care raltegravir Research resistance Retrovirus Conference rilpivirine sofosbuvir TDF/FTC tenofovir vaccination